Can sterile and pyrogen-free on-line substitution fluid be routinely delivered? A multicentric study on the microbiological safety of on-line haemodiafiltration.

BACKGROUND: Microbial contamination is characterized not only by the presence of bacteria, but also by high concentrations of biologically active by-products. They are potentially able to cross ultrafiltration and dialysis membranes and stimulate immunocompetent blood cells to synthesize cytokines. In turn, cytokine induction causes acute symptoms and has been incriminated in the long-term complications of haemodialysis patients. Infusion of large volumes of substitution fluids following ultrafiltration of microbially contaminated dialysis fluids may place patients on on-line therapies at particular risk. METHODS: In this study we evaluated 30 machines with a two-stage ultrafiltration system in routine clinical haemodiafiltration settings in six centres for 6 months. Microbiological safety was assessed monthly and at the last use of the filters by determining microbial counts, endotoxin concentration and cytokine-inducing activity. RESULTS: No pyrogenic episodes were observed during the study period. Double-filtration of standard dialysis fluid (range, <1-895 cfu/ml, 0.0028-4.6822 IU/ml) resulted in sterile substitution fluids with endotoxin concentrations well below the Ph.Eur. standard for haemofiltration solutions (range, 0.0014-0.0281 vs 0.25 IU/ml). Moreover, they did not differ from commercial haemofiltration solutions and depyrogenated saline. Likewise, there was no difference in the cytokine-inducing activity between the solutions tested. The high microbiological quality of the ultrafiltered dialysis fluid, which was in the same range as substitution fluid, translates into both the absence of cytokine induction by dialyser back-transport and a redundant safety mode of the on-line system by a second filtration step. CONCLUSION: On-line HDF treatment can routinely be provided with ultra-pure dialysis fluids and sterile substitution fluids at pyrogen-free levels. The online preparation of substitution fluids thus can be considered microbiologically safe.

[Changes in body fluid compartments estimated by multifrequency bioelectric impedance analysis in patients treated by hemodialysis]. / Hemodialízist kísérö folyadéktér változások nyomon követése multifrekvenciás bioelektromos impedancia analízissel.

Bioimpedance is a simple non-invasive method of assessing body composition. The aim of this study was to investigate the effect of changes in body fluid related to haemodialysis on measured bioimpedance parameters, to determine correlation between bioimpedance data and the volume of ultrafiltratum, and to collect data on alterations of body fluids resulting from a treatment. Measurements were done on 19 patients (mean age 36.7 years) prior to and after haemodialysis. After dialysis we found significantly higher impedance values on each measured frequency (1, 5, 10, 50, 100 kHz) (p < 0.001). An inverse correlation was found between the changes in body weight (x) and resistance at 50 kHz (y): y = 8.4830-2.1850x (r = 0.7167, p < 0.01). Total body water calculated by bioimpedance analysis (BIA) decreased from 38.47 +/- 8.567 litres (56.07%) to 35.06 +/- 8.045 significantly (p < 0.001), and the reduction of extracellular water proved to be also significant [from 15.76 +/- 2.992 litres (22.97%) to 14.06 +/- 2.736 litres (21.17%), p < 0.001]. The relationship between the change in calculated body water (x) and the volume of ultrafiltratum (y) is: y = -0.5590 + 0.5864x (r = 0.4898 p < 0.05), bioimpedance in our study overestimated the fluid loss by 55%. The intradialytical shifts between extra- and intracellular spaces might be responsible for the difference in the two values.

Catheter types and their abdominal implantation in peritoneal dialysis.

In the period 1976-1990 a total of 282 chronic uraemic patients were put to peritoneal dialysis by means of abdominally implanted Tenckhoff catheters, out of which 170 had to be replaced. Description of the catheter types is followed by a summary of the rules of surgical implantation and postoperative treatment that should be observed for the peritoneal dialysis to be effective. Discussed are the causes and percentage distribution of changes that call for catheter replacement, finally the alternatives of conservative therapy.

Peritoneal dialysis in Hungary.

In 1991 the technical conditions and the number of patients receiving peritoneal dialysis were surveyed in the Hungarian nephrology and dialysing units. Not only the number of patients with chronic uraemia (undergoing dialysis + transplantation) is lower in this country as compared to the European average (106 and 236 per one million people, respectively), but also their distribution according to the type of treatment is different. For several years patients under intermittent peritoneal dialysis make up more than 10% of the cases and those under continuous ambulatory peritoneal dialysis less than 2% (in Europe: < 2% and 4-43%, respectively). The survey also included the types of solution, disinfection and connecting devices used in peritoneal dialysis, as well as the incidence of peritonitis and the administration of antibiotics. The principles of biocompatibility, the function of interleukin, as well as the effectiveness and the conditions of continuous ambulatory peritoneal dialysis are summarized.

[Complications of peritoneal dialysis: sclerosing peritonitis]. / A peritonealis dialízis szövödménye: a sclerotizáló peritonitis.

One chronic uraemic patient was treated with intermittent peritoneal dialysis. During the 9th month decreasing of ultrafiltration and increasing of the blood level of low-molecular weight substances was observed. Laparotomy was performed twice because of increased intraperitoneal bleeding. During the operation peritoneal thickening, intestinal adhesion and diffuse bleeding was noticed. The patient died because of ileus. The most probable cause of sclerosing peritonitis was due to the formalin solution, which was used for the disinfection of the Tenckhoff catheter. The causes and prevention of sclerosing peritonitis has been summarised.

Sclerosing peritonitis caused by disinfectant in a patient under peritoneal dialysis.

An uraemic patient under intermittent peritoneal dialysis was found in the 9th month of treatment to present ultrafiltration drop and increase of low-molecular weight substances. Two instances of laparotomy for heavy abdominal bleeding revealed peritoneal thickening, laminar intestinal concrescence and diffuse haemorrhage. The patient died in the 13th month of treatment under symptoms of ileus. Other reasons excluded, sclerosing peritonitis was attributed to the formalin solution employed as disinfectant for the abdominal catheter. The causative factors are listed together with the chances of prevention.

Combined peritoneal and haemodialysis therapy for chronic renal insufficiency.

Twenty-three patients with chronic uraemia were treated for an average of 8.5 months with intermittent peritoneal dialysis. When hypervolaemia developed and/or the volume of low-molecular weight substances increased, the therapy was complemented by one or two sessions of haemodialysis per week. The combined treatment was carried on for 4.1 months on average, in consequence of which the general condition improved, body weight reached the optimum, blood pressure diminished, turned normal and could be controlled by drugs. In the wake of the therapy carbamide nitrogen and creatinine levels dropped significantly, serum total protein and albumin values increased. At the close of the observation period 3 patients remained under combined therapy, 2 had undergone cadaveric kidney transplantation, 18 were transferred to chronic haemodialysis. Thoughts are evolved about the advisability of intermittent peritoneal dialysis and combined therapy in the care for uraemic patients.

[Combination of peritoneal dialysis and hemodialysis in the treatment of chronic renal insufficiency]. / Peritonealis dialízis és haemodializis kombinációja a krónikus veseelégtelenség kezelésében.

In case of 23 patients, who had been treated for 8.5 (2-10) months with intermittent peritoneal dialysis, the peritoneal dialysis was supplemented once or twice a week by haemodialysis for 8.5 months. This combined way of treatment was favourable in cases of hypervolemia and/or of increased level of substances of small molecular weight. The average duration of this kind of treatment was 4.1 (1.5-11) months. In the course of treatment the general condition of the patients improved. When they regained their optimal bodyweight, their blood pressure got normalized or their hypertony decreased or it could be regulated by drug therapy. At the effect of this treatment, the carbamid nitrate and serum creatinin significantly decreased and the serum total protein and albumin levels increased. Two of the patients underwent cadaver kidney transplantation, and 18 of them have been treated by hemodialysis, 3 of them are being treated in this combined way even now. The authors discuss the role of intermittent peritoneal dialysis and that of the combined treatment in the management of uremic patients.

Broken piece in the lungs: a complication of haemodialysis via subclavian cannulation.

For a total of 349 haemodialysis sessions in 35 patients, 50 special subclavian cannulations were performed. The catheters were implanted infraclavicularly by the Seldinger technique. The average duration of the cannulation period was 26.6 days and the number of dialysis sessions per catheter was 7. Aspects of subclavian cannulation together with indications and complications are described. In three chronically uraemic patients, after 1, 5, and 6 weeks of single-needle haemodialysis, it was noticed that the catheter tip (3-5 cm) inserted into the subclavian vein had broken off. The broken pieces, lodged in the segmental pulmonary arteries, never caused any complication during the observation periods as long as 6, 14 and 33 months. Therefore their removal, either open or transluminal, seemed unnecessary. To prevent complications of similar type it is advisable to avoid single-needle dialysis. Recommended instead is either the double-needle method or the use of a double-lumen catheter.

[Complications in hemodialysis performed by catheterization of the subclavian vein]. / A véna subclavia katéterezésével végzett haemodialízis szövödményei.

Hemodialysis was performed in 349 cases on 35 patients with 50 special subclavian catheters. The catheters were inserted infraclavicularly with Seldinger's technique. The cannulation period was 26.6 (1-148) days and on the average 7 hemodialyses (1-63) were performed through 1 catheter. The aspects of subclavian catheterization, indication and complications are described. In 3 patients suffering from chronic uremia the end of the catheter (3-5 cm) in the subclavian vein was found broken after 1-5-6 weeks long "single-needle" dialysis. The broken end became fixed into the segmental artery of the lung and did not cause any complication during the long (6-14-33 months) observation period, thus its open or transluminal removal was not considered necessary. In the opinion of the authors the "single-needle" hemodialysis should be avoided to prevent similar complications. The use of the "two-needle" treatment or a catheter with double lumen is advisable.

Effect of hyperosmolar peritoneal dialysis fluid on the elimination of small- and medium-molecular substances.

The efficiency of peritoneal dialysis by the use of hyperosmolar dialyzing fluid (680 mOsm/1) was studied in 7 patients with chronic renal failure. The results were referred to the control values obtained in the first and in the terminal periods. In the course of treatment by means of the solution of high osmolarity the clearance of small- and medium-molecular substances increased. A significant increase in ultrafiltration was demonstrable. Protein loss and elevation of the blood glucose levels were noted as side-effects.